Management of Ectopic Pregnancy

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What is an ectopic pregnancy?

In normal pregnancy, after the egg has been released from the ovary and fertilised, it travels down the fallopian tube and into the womb (uterus) where it attaches to the lining and continues to develop. In an ectopic pregnancy, the fertilised egg implants outside the womb (usually in the fallopian tube) and continues to grow and enlarge. The fallopian tube is not designed to support a pregnancy and so as the pregnancy grows, the tube is stretched and eventually will rupture.

3 to 5 out of 100 ectopic pregnancies occur in other places. The pregnancy implants somewhere other than the tube.

A non-tubal ectopic pregnancy might be:

• An interstitial ectopic: the pregnancy implants in the top corner of the uterus near the fallopian tube
• A cervical ectopic: the pregnancy implants in the cervix (the neck of the womb)
• A scar ectopic: the pregnancy implants in the scar from a previous Caesarean section
• A cornual ectopic: the pregnancy implants in a corner of the uterus which itself has not formed normally
• A heterotopic pregnancy: a twin pregnancy where one is in the correct place but one is ectopic
• An ovarian ectopic: the pregnancy implants in an ovary
• An abdominal pregnancy: the pregnancy implants somewhere within the abdomen

These are all rare conditions with individualised treatment. Ectopic pregnancy can be very difficult to diagnose. An ectopic pregnancy can be life threatening because as the pregnancy gets bigger it runs out of space to grow and can potentially rupture (burst) causing severe pain and internal bleeding.

What are the causes of ectopic pregnancy?

Ectopic pregnancy occurs in about 1 in 100 pregnancies. The fertilised egg normally spends 4 to 5 days travelling down the fallopian tube to the womb where it implants. The most common reason for an ectopic pregnancy is damage to the fallopian tube, resulting in a blockage or narrowing which may delay the passage of the fertilised egg allowing it to implant in the tube.

Any woman of child bearing age who is sexual active could be at risk of an ectopic pregnancy.

Your risk increases if:

• You have had a previous ectopic pregnancy
• You have a damaged fallopian tube, the main causes of damage include: previous surgery to your fallopian tubes including sterilisation and previous infections in your fallopian tubes i.e. acute pelvic inflammatory diseases
• Your pregnancy is a result of an assisted conception: in-vitro fertilisation(IVF) or Intracytoplasmic sperm injection (ICSI)
• You become pregnant on the progesterone only contraceptive pill (mini pill) or when you have an intrauterine device (IUD/Coil)

What are the signs and symptoms?

Each woman is affected differently by an ectopic pregnancy and due to symptoms varying so much, some may have a few symptoms whilst others may have many.

The symptoms include:

• Pain in your lower abdomen- it may be one sided
• Vaginal bleeding
• Pain in the tip of your shoulder – this occurs due to blood leaking into the abdomen
• You may have diarrhoea or pain on opening your bowels
• Severe abdominal pain/lightheadedness/fainting/collapse

How is it diagnosed and treated?

Ectopic pregnancies are sometimes difficult to diagnose. Firstly we will do a urine pregnancy test and if it is positive you will have a scan of your pelvis. This usually will be an internal scan through the vagina. If we cannot confirm a pregnancy in your womb then blood samples will have to be taken to measure your hormone levels. An ectopic pregnancy may be suspected when levels don’t rise appropriately. Sometimes we can see the ectopic pregnancy on the scan.

Blood tests alone cannot tell where the pregnancy is developing, but they can help monitor patients who might have a growing ectopic pregnancy. Confirmation of an ectopic pregnancy is usually by a Laparoscopy.

Surgical Treatment is a ‘key-hole’ surgical procedure where a telescope is passed through a small incision through your tummy button enabling the doctor to see the womb and fallopian tubes. Once it is proven that there is an ectopic pregnancy, surgery to remove it will be performed.

This is performed under a general anaesthetic and is the recommended treatment:

• If you are acutely unwell
• There is a live ectopic
• Your hormone level is very high
• The diagnosis is uncertain

The operation involves removing the tube affected by the pregnancy, as long as the other tube looks normal. If both tubes look damaged then we aim to just remove the pregnancy and leave the tube intact. Usually you can go home the day after the surgery, depending on your recovery. Occasionally, if the surgery is difficult or complicated an open operation or laparotomy may need to be performed. This is where an incision is made along the bikini line and it may mean a slightly longer stay in hospital.

Medical treatment

In certain clinical cases an ectopic pregnancy can be treated with medication that stops the development of the pregnancy and allows it to be reabsorbed by the body.

This treatment needs to be discussed on an individual basis as it is not suitable for all women. The treatment involves having an injection called Methotrexate injected into your buttock. (Please refer to separate leaflet explaining all about Methotrexate).

You will need to return to the early pregnancy unit for a series of blood tests to monitor your pregnancy hormones. Until your hormone levels are back to normal, it is important not to have sexual intercourse as this can increase the risk of rupture, and to avoid alcohol as this it may complicate the situation if you become unwell. During this time it is important to think of who you would contact in an emergency for support if you became unwell.

About 15% of women need a second injection and a smaller number may need surgery.

Some women have side effects from the treatment, which include increase pain, nausea, mouth ulcers, skin rashes and disturbances to GI System. If you have medical treatment, you will be advised to wait three months before trying for another pregnancy. This is because the drug can be harmful to an early pregnancy by reducing the amount of folic acid in your system.

Conservative or expectant management

This is sometimes described as ‘watchful waiting’. It means that you don’t have any active invasive treatment. Regular visits to the unit to ensure that the ectopic pregnancy is ending naturally.

You might be offered this treatment if:

• you are well and asymptomatic
• there is no sign on the ultrasound scan of bleeding internally
• your ßhCG levels are relatively low and during monitoring these levels continue to fall

If you do have conservative management, you will need repeated visits to hospital to have your pregnancy hormone levels checked. Until your results are back to normal, there is still a risk that your tube might rupture.

During this time it is important to think of who you would contact in an emergency for support if you became unwell. It is also important not to have sexual intercourse as this can increase the risk of rupture, and to avoid alcohol as this it may complicate the situation if you become unwell.

How soon can I return to normal activities and work?

Laparocopic surgery could mean an overnight stay or day case depending on your recovery and time of surgery. We would recommend that you take 2 to 3 weeks off work and gradually resume your normal activities. Before you leave the hospital, the nursing team will advise you about vaginal bleeding, wound care, infection and resuming sexual intercourse. If you have a laparotomy then your recovery time will be longer and the nursing and medical staff can advise you accordingly.

How will this affect future pregnancies?

Before trying for another baby you should allow yourself time to recover both physically and emotionally. We usually advise you wait until you have your next normal period, but you may find that emotionally you need to wait longer.

If you have had an ectopic pregnancy you have a 10% greater risk of having further ectopics. If your fallopian tube has been removed and the other tube is normal there is still a good chance of conception taking place although it may take a little longer. The most recent research suggests that fertility is reduced by 20 to 25% (opposed to the expected 50%). This is why we remove the damaged tube, as leaving it behind does not improve your fertility significantly but it does increase your risks of further ectopic pregnancies.

If you have had an ectopic pregnancy you should consult your doctor as soon as you suspect you are pregnant. Early monitoring of the pregnancy is important so that another ectopic pregnancy can be excluded. We are happy to see you for a scan at about seven weeks in the early pregnancy clinic.

When is it ok to start having sex again?

This will depend on how you are feeling after the ectopic pregnancy and what treatment you have had. Medically it is safe to start having sexual intercourse when you have stopped bleeding. We would recommend that you use barrier contraception until after your next period if you are wishing to try and conceive again.

How will it affect me emotionally?

Ectopic pregnancy can be a very traumatic and painful experience. It is likely you would have been rushed to the operating theatre with very little time for psychological adjustment. Much of what has happened to you will have been out of your control, maybe leaving you in a state of shock. You will be recovering from surgery; you and your partner will need to cope with the loss of your baby and often the loss of part of your fertility. Your feelings may vary enormously in the weeks and months following your loss. Listed below are some useful contacts that may help in you and your partner’s recovery.

Contact numbers

NHS Choices 111 when you need medical help fast but it’s not a 999 emergency. The service is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile phones.

Further support:

Association of Early Pregnancy Units 
Infertility Network UK 
Miscarriage Association 

References:

• BSUH NHS TRUST(2011) GP001 Early Pregnancy Unit Clinical Guidelines
• Patient UK Information leaflets Women’s Health Category
• Royal College of Obstetricians and Gynaecologists 
• National institute for Heath and Clinical Excellence